Category: Physical Therapy
BFR therapy for tendon in clinical settings.

Blood Flow Restriction Training for Tendon Health

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Blood flow restriction (BFR) training, a novel technique in the field of rehabilitation and sports medicine, has been gaining traction because of its benefits in muscle growth and recovery. Although the validity of BFR’s role in muscle hypertrophy is well documented, the question has arisen as to whether the low loads associated with BFR therapy leave the associated tendons behind in terms of growth, thus increasing the risk of tendon injury. This blog post delves into what BFR training entails, the science behind its effectiveness, and how it can be applied to treat and improve tendon size and strength both for rehabilitation and overall health.

What is Blood Flow Restriction Training?

Blood flow restriction training, also called blood flow restriction therapy, involves applying a cuff to the proximal part of the arm or leg to safely restrict both venous and arterial blood flow to the involved limb. This type of training is typically conducted while performing low-intensity resistance exercises, between 30-40% of one’s one repetition maximum (1RM). The idea is to create an environment within the limb that mimics the effects of high-intensity workouts (>65% 1RM), thereby promoting muscle strength and hypertrophy with significantly reduced loads. The reduced load is critical because many people can not lift heavy loads but still need the stimulus to increase muscle size and strength. These individuals may be older, injured, post-surgical, or just not able to tolerate heavy weights.

The Science Behind BFR Training

The mechanism of BFR training hinges on the concept of creating a hypoxic (low oxygen) environment for the targeted muscles. When the muscles are deprived of oxygen, they are forced to work harder to perform even low-intensity exercises. When hypoxia is combined with muscular tension, muscle protein synthesis, type II muscle fiber recruitment, and cellular swelling, which are all critical factors in muscle growth and recovery, are stimulated. Also evidence of both local and systemic endocrine signaling that may play a role in strength and hypertrophy has been found.

BFR training leads to the accumulation of metabolites further down the limb or distal to the cuff. Metabolites like lactate and hydrogen ion, which are believed to help in the production of growth hormone and testosterone (Yinghao et al., 2021), stem cells (Montgomery et al., 2019), and vascular endothelial growth factors (Ferguson et al., 2018) all critical players in tissue repair and growth. Notably, the application of BFR at low intensities helps prevent the strain and stress that high-intensity workouts impose on muscles and tendons, making it a suitable option for both injury rehabilitation and post-surgical rehabilitation.

BFR therapy for tendon in clinical settings.
SmartCuffs 4.0 during a TRX squat.

BFR Training for Tendon Health

Tendons, the tough bands of fibrous connective tissue that connect muscles to bones, require a balanced approach to strengthening healthy tissue and healing injured tissue. BFR has been shown to increase size and strength in healthy tendons (Vergara et al., 2023), tendinopathies (Yow et al., 2018), and post-surgical rehabilitation(Gerber et al., 2004). Tendon injuries, such as tendinopathies, are notoriously slow to heal because of the low blood supply to these structures. Current thinking is that damaged tissue never fully heals, so new tissue needs to be formed around the injured tissue. (Docking & Cook, 2019) Herein lies the potential of BFR training to contribute positively to tendon health:

1. Enhanced Collagen Synthesis: Research indicates that BFR therapy can increase the synthesis of collagen in tendons, which is vital for their strength and flexibility. The stress caused by the restricted blood flow followed by reperfusion when the cuffs are released (free flow) may encourage collagen production in the tendon tissues. Proper nutrition plays an important role in enhancing collagen synthesis. (Baar, 2019)

2. Reduced Load on Tendons: Since BFR training can be performed with lower loads, it allows individuals with tender or healing tendons to strengthen the muscles around the tendon without placing excessive stress on it. This is particularly beneficial in the early stages of tendon rehabilitation, both post-surgical and during the injury process.

3. Pain Management: There is evidence that BFR training can help in reducing pain perception, which is a common issue in chronic tendinopathies. The exact mechanism is not well understood but is believed to be linked to the muscle fatigue induced by BFR, which may alter pain signals sent to the brain.

BFR cuffs for ACL injury
Blood Flow Restriction Therapy for Achilles’ Tendinopathy

Implementing BFR Training in Tendon Rehabilitation

To safely incorporate BFR training in the context of tendon health, it is crucial to follow a structured approach under professional guidance. Here’s a step-by-step guide on how to get started:

– Consultation with a Healthcare Professional: Before beginning any new exercise regimen, particularly one involving blood flow restriction training, it is essential to consult with a healthcare professional, such as a physical therapist or a sports medicine doctor certified in BFR. They can provide guidance based on the specific tendon issue and overall health. Not everyone is a candidate for BFR based on injury type and the individual’s medical history. Diagnostics such as MRI or Diagnostic Ultrasound may be necessary to understand the degree of injury and how long the recovery process may take.

– Proper Equipment: Use FDA-listed blood flow restriction cuffs that are designed for this type of training. These BFR cuffs offer precise control over the amount of applied pressured via limb occlusion pressure calibration, which ensures safety and effectiveness.

– Starting with Low Intensity: Begin with exercises that are low in intensity but effective in stimulating the muscles around the injured tendon. Gradually increase the intensity as tolerated. My favorite technique is to use isometric contractions in the early stages, three times per week.

– Monitoring and Adjustment: Regularly monitor the response to BFR training. Any signs of extreme discomfort or adverse effects should prompt an immediate reassessment of the technique and adjustments by a professional.

– Integration with Other Therapies: Combine BFR training with other rehabilitation modalities such as Extra Corporeal Shock Wave Therapy (ECSW), Dry Needling (DN), Instrument Assisted Soft Tissue Manipulation (IASTM), or Active Release Technique (ART) for the best results. Don’t forget to address not only the injured site but also look for tissue and joint movement abnormalities (aka densification of the tissue) above and below the focused tissue.

Conclusion

Blood flow restriction training represents a promising advancement in the rehabilitation of tendon injuries and the enhancement of tendon health. By allowing for muscle and strength development at lower intensities, BFR training can help manage the delicate balance between exertion and recovery in tendon rehabilitation. With proper implementation and supervision, BFR can be a valuable tool in the arsenal against tendon-related issues, offering a safe and effective pathway to faster recovery and stronger, more resilient tendon structures.

For anyone considering BFR training, particularly for tendon health, it’s crucial to approach this method thoughtfully and under the guidance of professionals who can tailor the program to individual needs and ensure safety throughout the process. As research continues to evolve, the scope and efficacy of BRF training will become more apparent, potentially opening new avenues for effective treatment options in physical therapy, sports performance, and longevity.

 

About the Author:

Ed Le Cara, RN, DC, PhD, MBA, ATC, CSCS is the owner and full-time clinician at Body Lounge Park Cities in Dallas, TX, and the director of education for SmartTools.  Dr. Le Cara can be reached on LinkedIn.

 

 

Reference list

Baar, K. (2019). Stress Relaxation and Targeted Nutrition to Treat Patellar Tendinopathy. International Journal of Sport Nutrition and Exercise Metabolism ,  29 (4), 453-457. https://doi.org/10.1123/ijsnem.2018-0231

Docking, S. I., & Cook, J. (2019). How do tendons adapt? Going beyond tissue responses to understand positive adaptation and pathology development: A narrative review. J Musculoskelet Neuronal Interact,  19 (3), 300–310.

Ferguson, R. A., Hunt, J. E. A., Lewis, M. P., Martin, N. R. W., Player, D. J., Stangier, C., . . . Turner, M. C. (2018). The acute angiogenic signalling response to low-load resistance exercise with blood flow restriction. Eur J Sport Sci , 1-10. https://doi.org/10.1080/17461391.2017.1422281

Gerber, C., Meyer, D. C., Schneeberger, A. G., Hoppeler, H., & von Rechenberg, B. (2004). Effect of tendon release and delayed repair on the structure of the muscles of the rotator cuff: an experimental study in sheep. J Bone Joint Surg Am ,  86-A (9), 1973-1982.

Montgomery, R., Paterson, A., Williamson, C., Florida-James, G., & Ross, M. D. (2019). Blood Flow Restriction Exercise Attenuates the Exercise-Induced Endothelial Progenitor Cell Response in Healthy, Young Men. Frontiers in Physiology, p. 10. https://doi.org/10.3389/fphys.2019.00447

Tendinitis | UK Healthcare. https://www.ukhealthcare.uky.edu/orthopaedic-surgery-sports-medicine/conditions/general-orthopaedics/tendinitis

Vergara, I. B., Puig-Diví, A., Alonso, B. A., & Milà-Villarroel, R. (2023). Effects of low-load blood flow restriction training in healthy adult tendons: A systematic review and meta-analysis. Journal of Bodywork and Movement Therapies.

Yinghao, L., Jing, Y., Yongqi, W., Jianming, Z., Zeng, G., Yiting, T., & Shuoqi, L. (2021). Effects of a blood flow restriction exercise under different pressures on testosterone, growth hormone, and insulin-like growth factor levels. Journal of International Medical Research ,  49 (9), 030006052110395. https://doi.org/10.1177/03000605211039564

Yow, B. G., Tennent, D. J., Dowd, T. C., Loenneke, J. P., & Owens, J. G. (2018). Blood flow restriction training after Achilles tendon rupture. The Journal of Foot and Ankle Surgery ,  57 (3), 635-638.

How Long Do Soft Tissue Injuries Take to Heal

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How Long Do Soft Tissue Injuries Take to Heal

Everyone has likely experienced a soft tissue injury at some point during their life — from injuries as severe as a torn rotator cuff to as simple as an ankle sprain. And the first question usually asked is, how long is this going to take to heal? 

The answer to that question is complicated and depends on a host of factors and conditions. Not all soft tissue is created equally, and therefore, not all soft tissue injuries take the same amount of time or rehabilitation to recover. 

What Is Soft Tissue?

Soft tissue plays a crucial role in your body’s makeup, movement, and ability to function. It is the unhardened parts of your body, such as muscles, tendons, and ligaments, that help support and connect your body. 

Each soft tissue, from muscles to ligaments, is constructed of collagen, elastin, and ground substance. Ground substance is a gel-like material that is active in the movement and development of tissues. The amount of each of these in the soft tissue gives it its properties and helps determine its function. These properties include strength, the ability to stretch (extensibility), and the ability to recoil from being stretched (elasticity). 

What Is a Soft Tissue Injury?

If you have ever sprained your ankle, you know just how severe the pain from that type of injury can be. 

These kinds of injuries are relatively common in sport or physical activity. They are usually the result of overstressed muscles, which become weaker over time, leading to a soft tissue injury. 

Common types of soft tissue injuries include sprains, strains, tendinitis, bursitis, and other contusions. Sometimes more severe and serious soft tissue injuries occur, such as rotator cuff, Anterior Cruciate Ligament (ACL), and Medial Collateral Ligament (MCL) injuries.

Stages of Healing for Soft Tissue Injuries

The amount of time it takes for a soft tissue injury to heal depends on many factors and is specific to each person and their circumstances. Those factors include a person’s age, fitness level, chronic conditions, and other medical issues. It also depends on how severe the injury is and what tissue or body part is injured. 

Soft tissue healing occurs in three phases: inflammatory, proliferation, and remodeling. Because of the nature of soft tissue healing, these phases often overlap to some degree.

Inflammatory Phase: 0 – 6 days

This first phase begins on the day the injury occurs and can last up to six days. Swelling around the injury is extremely common in this phase. Healing cells start their work of cleaning up and removing the dead tissue.

Proliferation Phase: Day 6 – Day 24

Swelling will subside as the dead tissue is removed, and type III collagen is introduced to produce new tissue. During this phase, the injured area will be quite weak because this newer tissue does not possess the same qualities and strength as normal tissue.

Remodeling Phase: Day 21 – 2 years

Finally, that type III collagen is converted into type I collagen, which is present in scar tissue. As soft tissue goes through the healing process, the body creates scar tissue to replace the damaged tissue. This last phase can take up to two years for the injury to completely heal, depending on its type and severity.

With the loss of muscle mass and strength from a soft tissue injury, many people need the help of physical therapy to regain strength and mobility in the affected body part. This is important so that the person can use that body part normally again. 

How BFR Can Help with Soft Tissue Injury Healing

Blood Flow Restriction (BFR) training offers significant benefits for physical therapy and soft tissue injury rehabilitation. 

When blood flow is restricted, the injured area recruits muscle fibers. These fibers help facilitate an increase in muscle mass. Furthermore, the results take less time than traditional training modalities and rehabilitation programs. 

By understanding soft tissue and the phases of healing, we can better determine the sense of the time it takes for specific injuries to heal. 

 

How to Use BFR Bands for Legs & More

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How to Use BFR Bands | Crucial Tips for First Timers

If you’re visiting this blog, you’ve likely heard of BFR, or Blood Flow Restriction training. It’s also likely that you’re interested in learning more about BFR and how to use BFR bands or cuffs for training and rehabilitation for the first time. 

BFR training is when you place cuffs or bands around a limb during exercise to maintain arterial inflow to the muscle while at the same time preventing venous return of the blood to the heart. 

Guide to Using BFR for the First Time

As a beginner, you need to decide what type of cuff or band to use. BFR cuffs allow you to precisely control the amount of pressure and the restriction to blood flow, making them not only consistent but also much safer than bands. 

Before beginning a training session, perform a light warmup such as walking or light cycling. Follow that five-minute warmup with roughly 15 un-cuffed reps with whatever weight you plan to use for your first set of BFR. To find the best weight, start on the lighter side and experiment with what works best for you. 

Now that you’re ready to train, wrap the BFR cuff around the top portion of your legs or arms. Depending on whether you’re using cuffs or bands, remember to not wrap too tightly to avoid numbness or tingling. 

Dos and Don’ts of BFR

Do lift much lighter weights than you think you need. One of the primary advantages of BFR training is that you can train by lifting lighter loads at a lower intensity. However, when lifting lighter weights at a lower intensity, you do want to perform more reps and longer sets with shorter rest periods in between. 

Don’t be afraid to start slow. In other words, don’t overdo it. This is a very real temptation when beginning a new training program or strategy. Most patients or athletes get excited and want to go all-in and see results immediately. Those results will come soon enough. But as a beginner, it’s critical to listen to your body, take it slow, and take breaks if needed. Work your way up to longer sets. 

How Do You Know If BFR Is for You?

BFR training benefits a wide range of people. Those who have mobility issues, such as those who are in a cast, bed-ridden, elderly, or post-op, will benefit.

As you begin your BFR training, it’s important to consult with your physician before starting a new exercise program. Invest in the proper equipment and start off slow and deliberate. Build up your training from there and you’ll discover BFR is a game-changer when it comes to seeing results and reducing the risk of injury to your muscles, joints, and tissue.